By Marc E. Childs, MD, Pediatrics, CareMount Medical
April 5, 2021
A rite of passage in spring is getting kids ready for warm weather activities and sports, day camp and sleepaway camp. As the world is cautiously opening up, the prospect of getting children out of the house and into the fresh air is looking bright, compared to last summer when activities were up-ended by the pandemic. For the majority of kids who have not tested positive for the virus that causes COVID-19, all they need is a routine medical check-up before they participate in sports or attend camp.
For the more than 3.34 million children who have tested positive for COVID-19, their situation is more complicated because there are still many unknowns about the disease and its after-effects. Most children infected by the virus have mild symptoms or have no symptoms and, rarely, others can get severely ill requiring hospitalization, intensive care, or a ventilator to help them breathe. Groups such as the American College of Cardiology (ACC) and the American Academy of Pediatrics (AAP) have developed guidelines for physicians to help them evaluate if and when children who have tested positive for SARS-CoV-2 should return to physical activity and sports.
There is consensus that children and adolescents who have had a positive COVID-19 test within the prior 6 months should visit their doctor for a complete physical examination before resuming sports and physical activities. The examination should take place greater than 14 days after symptoms have resolved. Importantly, the examination should include particular emphasis on assessing the child’s cardiac health regardless of the severity of their illness. Many pediatricians use the American Heart Association 14-element screening checklist to evaluate for any cardiac symptoms including chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations, or dizziness.
Every child and every case is unique, but general guidance is as follows for children 10 years of age and older:
• If the child is asymptomatic or has mild symptoms (less than 3 days of symptoms and no fever), and the pre-participation screening evaluation and examination are normal, no further cardiac testing is warranted. These children may return to physical activity.
• For children with moderate illness: 3 or more days of symptoms, fever at any point during the illness, not hospitalized or if physical exam reveals any new or concerning cardiac issues, the physician may request an echocardiogram. Patients with a normal ECG can be cleared for participation as per above. If the ECG results are abnormal, a pediatric cardiologist should be consulted and additional testing may be required.
• Patients with severe illness (hospitalization, abnormal cardiac testing or multisystem inflammatory syndrome in children – MIS-C – associated with COVID19 infection) should not exercise for at least three to six months and should be evaluated by a pediatric cardiologist prior to resuming training or competition. They may require other tests based on signs or symptoms.
The AAP also recommends that doctors educate all patients and families to monitor for “chest pain, shortness of breath out of proportion for upper respiratory tract infection, new-onset palpitations or syncope when returning to exercise”.
Most pediatric patients will be able to be easily cleared for participation without extensive cardiac testing, but parents and caregivers should schedule an appointment with their child’s pediatrician as soon as possible to ensure that these patients have fully recovered, have no evidence of damage to the heart.